Medial Patellofemoral Ligament Augmentation Repair for Primary Patellar Dislocation With Concomitant Chondral or Osteochondral Injury in Children and Adolescents: Outcomes at Minimum 2-Year Follow-up

Background

Treatment of primary patellar dislocation (PPD) with chondral or osteochondral injury without patellar stabilization in the adolescent population may lead to unsatisfactory outcomes. Surgical treatment, with or without traditional medial patellofemoral ligament (MPFL) reconstruction, is a topic of interest.

Purpose

To compare postoperative outcomes and rates of patellar redislocation and return to the operating room (OR) in patients who sustained a PPD with chondral or osteochondral injury and were surgically treated with versus without suture tape augmentation repair of the MPFL.

Study Design

Cohort study; Level of evidence, 3.

Methods

Adolescents who sustained a PPD with chondral or osteochondral injury confirmed via magnetic resonance imaging (MRI) and who were treated by a single surgeon between January 2009 and November 2020 were retrospectively reviewed. Patients were grouped into those who underwent chondral or osteochondral treatment with suture tape augmentation repair of the MPFL (ST group; n = 20) and those who did not have suture tape augmentation or repair (no-ST group; n = 20; 11 patients within the no-ST group did undergo medial imbrication). Demographic characteristics, postoperative knee range of motion, pre- and postoperative radiographic measurements, and preoperative MRI parameters were recorded, and minimum 2-year patient-reported outcomes were collected. Data were compared between the ST and no-ST groups.

Results

The mean patient age was 15.02 years (range, 12.64-17.61 years) in the ST group and 14.18 years (range, 10.56-16.38 years) in the no-ST group, with a mean follow-up of 3.63 years (range, 2.01-6.11 years) in the ST group and 4.98 years (range, 2.23-9.03 years) in the no-ST group. Significantly more patients returned to the OR in the no-ST group compared with the ST group (7 [35%] vs 0 [0%]; P = .008). Further patellar stabilization with an MPFL allograft (n = 5) and manipulation under anesthesia (n = 2) were reasons for returning to the OR. There were no redislocation events in the ST group.

Conclusion

Treating PPDs with chondral or osteochondral injury using suture tape to augment and repair the MPFL has promising advantages over not repairing it-including lower rates of postoperative patellar instability and return to the OR.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents

BACKGROUND

The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture.

METHODS

A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer.

RESULTS

Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%).

CONCLUSION

Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice.

CLINICAL RELEVANCE

In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum

BACKGROUND

There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction.

PURPOSE

To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed.

RESULTS

A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement.

CONCLUSION

IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

BACKGROUND

Chlorhexidine gluconate (CHG) solution is commonly used as an antiseptic irrigation for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG on articular cartilage has been reported, the full extent of CHG-related chondrotoxicity and its effects on the extracellular matrix and mechanical properties are unknown.

PURPOSE

To investigate the in vitro effects of a single 1-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants.

STUDY DESIGN

Controlled laboratory study.

METHODS

Articular cartilage explants (6 per group) were harvested from femoral condyles of the porcine stifle and sectioned at tidemark. Explants were bathed in CHG solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) for 1 minute, followed by complete phosphate-buffered saline wash and culture in chondrogenic medium. At 7 days after CHG exposure, cell viability, matrix content (collagen and glycosaminoglycan [GAG]), and compressive mechanical properties (creep indentation testing) were assessed.

RESULTS

One-minute CHG exposure was chondrotoxic to explants, with both 0.05% CHG (2.6% ± 4.1%) and 0.01% CHG (76.3% ± 8.6%) causing a decrease in chondrocyte viability compared with controls (97.5% ± 0.6%; P < .001 for both). CHG exposure at either concentration had no significant effect on collagen content, while 0.05% CHG exposure led to a significant decrease in mean GAG per wet weight compared with the control group (2.6% ± 1.7% vs 5.2% ± 1.9%; P = .029). There was a corresponding weakening of mechanical properties in explants treated with 0.05% CHG compared with controls, with decreases in mean aggregate modulus (177.8 ± 90.1 kPa vs 280.8 ± 19.8 kPa; P < .029) and shear modulus (102.6 ± 56.5 kPa vs 167.9 ± 16.2 kPa; P < .020).

CONCLUSION

One-minute exposure to CHG for articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. This raises concern for the risk of mechanical failure of the cartilage tissue after CHG exposure.

CLINICAL RELEVANCE

Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.

Does Liposomal Bupivacaine Injectable Suspension Peripheral Nerve Block Further Aid in Decreasing At-home Narcotic Utilization in Children and Adolescents After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Opioid misuse and addiction among children and adolescents is an increasingly concerning problem. This study sought to determine whether liposomal bupivacaine injectable suspension admixture administered as a single-shot adductor canal peripheral nerve block (SPNB+BL) would decrease utilization of at-home opioid analgesics after anterior cruciate ligament reconstruction (ACLR) in adolescents compared with single-shot peripheral nerve block with bupivacaine (SPNB+B) alone.

METHODS

Consecutive ACLR patients with or without meniscal surgery by a single surgeon were enrolled. All received a preoperative single-shot adductor canal peripheral nerve block with either admixture of liposomal bupivacaine injectable suspension with 0.25% bupivacaine (SPNB+BL) or 0.25% bupivacaine alone (SPNB+B). Postoperative pain management included cryotherapy, oral acetaminophen, and ibuprofen. A prescription for 10 doses of hydrocodone/acetaminophen (5/325 mg) was provided in a sealed envelope with instructions to only use in the case of uncontrolled pain. Pain using the visual analog scale; number of consumed narcotics, acetaminophen, ibuprofen, and pain treatment satisfaction for the first 3 postoperative days were recorded. Statistical analysis was performed.

RESULTS

Fifty-eight patients were enrolled, the average age was 15±1.5 years (SPNB+B=32 patients, SPNB+BL=26 patients). Forty-seven patients (81%) did not require home opioids postoperatively. A significantly lower proportion of patients in the SPNB+BL group required opioids compared with control patients (7.7% vs. 28.1%, P=0.048). Average opioid use was 2 morphine milligram equivalents (MME), 0.4 pills (range, 0 to 20 MME). There were no differences in the visual analog scale or pain treatment satisfaction scores, other demographics, or other operative data. Inverse probability of treatment weighting analysis that was performed to account for any potential group differences revealed home opioid use between groups is significantly different (P<0.001).

CONCLUSIONS

Liposomal bupivacaine injectable suspension admixture administered as an adductor canal nerve block in adolescents undergoing ACLR effectively reduces home opioid usage postoperatively compared with bupivacaine alone.

LEVEL OF EVIDENCE

Level II-prospective comparative study.

Adolescent Athletes Achieve High Levels of Athletic and Daily Function After Arthroscopic Marrow Stimulation for Elbow Capitellar Osteochondritis Dissecans

Purpose

To determine the functional outcomes of adolescent athletes treated with arthroscopic marrow stimulation/microfracture for elbow capitellar osteochondritis dissecans (OCD).

Methods

The medical records for all patients younger than 18 years of age with capitellar OCD who underwent arthroscopic treatment at a single institution were retrospectively reviewed. The variables examined included patient characteristics, bone age, pre- and postoperative lesion grade/size and range of motion (ROM), intraoperative lesion grade/size, time to postoperative return to sport, and validated outcome scores.

Results

Twenty patients with 21 treated elbows met the study's inclusion criteria. Three patients were not available for follow-up, leaving 18 of 21 (85.7%) elbows in the final cohort. Mean age and follow-up was 14.1 and 4.4 years, respectively. All 18 elbows were treated with diagnostic arthroscopy, arthroscopic debridement with loose body removal as indicated, and marrow stimulation. Sixteen of 18 (88.9%) elbows returned to sports postoperatively, with 12 of 18 (66.7%) elbows returning to their primary sport at the same level or higher. Overall, there were significant improvements in elbow ROM (132.8°, range 120°-140° postoperatively, compared with 122.1°, range 80°-140° preoperatively) (P = .002) and excellent Quick Disabilities of the Arm, Shoulder and Hand scores (mean 2.3 ± 5.1), as well as Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow scores (mean 94.1 ± 8.7) in those who returned to sports. There was no correlation with outcome or return to sport for preoperative lesion grade/size, bone age, physeal status or open versus arthroscopic treatment.

Conclusions

Arthroscopic debridement and marrow stimulation for capitellar OCD in adolescent athletes leads to improvements in ROM, as well as a high rate of return to sport, and high levels of athletic and daily functional activity during follow-up, regardless of bone age and lesion grade/size at time of surgery.

Level of Evidence

Level IV, therapeutic case series.

Investigating Particulate Production in The Operating Suite Following the Use of Waterless Alcohol Based Dry Scrub Versus Traditional Hand Washing and Drying with Commonly Used Surgical Towels: An Experimental Study

BACKGROUND

An often-overlooked item that could cause contamination in the operating suite are the towels used for hand drying following surgical scrub. The purpose of this current study was to determine if there was a difference in the particulate count from different hand drying methods following surgical hand preparation.

METHODS

Three simulated hand drying groups were established: disposable sterilized surgical towels, reusable sterilized surgical towels, and a waterless alcohol-based dry rub. Particle size measurements of 0.3 µm, 5.0 µm, and 10.0 µm were collected at time zero and repeated every minute for 5 minutes for a total of 10 trials each.

RESULTS

Both the reusable and disposable towels produced significantly more particle matter in all size groups compared to the alcohol scrub control group. A comparison analysis and ANOVA testing demonstrated that alcohol dry scrub produced significantly fewer particles compared to both the disposable blue towels (P<0.01) and the reusable green towels (P<0.01). Disposable towels produced significantly more particles in the 0.3 µm count compared to reusable towels (P<0.05).

CONCLUSIONS

An alcohol-based dry rub without using a towel yielded the lowest amount of particulate formation in this experimental model, while reusable surgical towels produced the highest number of particles.

LEVEL OF EVIDENCE

Level II Experimental Study.

COVID-19 pandemic restrictions unmasks dangers of frequent injury mechanisms for common surgically treated pediatric fractures

PURPOSE

This study examined the volume and characteristics of common surgically treated fractures in children during the COVID-19 pandemic. The worldwide spread of COVID-19 affected the society in numerous ways. Social distancing led to changes in the types of activities performed by individuals, including children. Physicians saw a shift in orthopedic trauma volume and distribution. We predicted that with the change in activities children participated in, the number or type of injuries sustained would change as well.

METHODS

A retrospective review was performed of children who sustained a surgically treated fracture of the forearm, supracondylar humerus, femur, or any open fracture during the COVID-19 pandemic compared to the previous 2 years (pre-pandemic). Patient demographics, insurance status, and mechanism of injury were recorded. Statistical analysis was performed.

RESULTS

Review of the medical records identified 791 children. The number of fractures decreased from an average of 295 per year pre-pandemic to 201 during the pandemic (p = 0.09). During the pandemic, there was a decrease in injuries resulting from a fall from the monkey bars for supracondylar humerus (21.2% to 8.2%, p < 0.01) and for forearm fractures (15.5% to 4.3%, p = 0.04). In contrast, the frequencies of falls from a skateboard, hoverboard, scooter, or bicycle and falls from household furniture increased during the pandemic.

CONCLUSION

The observed decrease in monkey bar-related injuries provides further evidence as to the dangers of this piece of playground equipment in contributing to upper-extremity fractures in children.

LEVEL OF EVIDENCE

Level III: Prognostic and Epidemiological.

Do Continuous Peripheral Nerve Blocks Decrease Home Opioid Use Following Anterior Cruciate Ligament Reconstruction in Children and Adolescents? The Envelope Please

BACKGROUND

Levels of opioid misuse and addiction among children and adolescents have reached alarming proportions. Exposure to opioids after surgery for anterior cruciate ligament reconstruction (ACLR), which is commonly performed in young athletes, increases this risk. This study was designed to evaluate whether continuous peripheral nerve block (CPNB) with placement of an elastomeric reservoir ball, compared with single-shot peripheral nerve block (SPNB), would decrease the need for home opioid analgesia and improve pain control after ACLR in children and adolescents.

METHODS

Prospectively collected data from a consecutive cohort that underwent ACLR by a single surgeon were retrospectively reviewed. Patients who received ACLR with 72-hour CPNB were assigned to Group 1. Patients who received ACLR with SPNB were assigned to Group 2. Postoperative pain management included cryotherapy, oral acetaminophen, and ibuprofen. A prescription for 10 doses of hydrocodone/acetaminophen (5/325 mg) was provided in a sealed envelope with instructions that the prescription should only be used in the case of uncontrolled pain. Reports of no opioid use were corroborated by the unopened envelope and unfilled prescription.

RESULTS

One hundred and ninety-six patients were enrolled in the study (SPNB=114 patients, CPNB=82 patients). Average age was 15±1.5 years (115 female). A total of 138 patients (70%) did not need home opioid analgesia after surgery. Of the 58 patients (30%) that did there were 35 (30.7%) in the SPNB group and 23 (28.0%) in the CPNB group (P=0.659). There were no differences between groups in demographics, operative data, or visual analog scale scores on any postoperative day.

CONCLUSION

The findings of this study demonstrate equivalent pain control and opioid consumption in children and adolescents undergoing ACLR treated with either a CPNB or a SPNB. At-home opioid analgesia use can be negated after ACLR in 70% of children and adolescents. For the patients in this study who required opioids, average use was only 2 pills of 5 mg hydrocodone/325 mg acetaminophen, with no child using more than 10 pills.

LEVEL OF EVIDENCE

Level II-therapeutic.

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis

BACKGROUND

The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality.

PURPOSE

A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00).

RESULTS

Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location.

CONCLUSION

This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.

Use of an Accessory Anteromedial Portal to Facilitate Repair of Mid-Body Radial Tears of the Lateral Meniscus in Children and Adolescents

Meniscal tears in adolescent patients are commonly treated with repair to preserve meniscal tissue and prevent future degenerative changes. Historically, meniscal tears best suited for repair are acute vertical tears in patients aged <40 years with a normal mechanical axis, >1 cm and <4 cm in size, within the red-red zone, and concurrent with anterior cruciate ligament reconstruction. However, with continued advancements in technology and the development of new techniques, the possibilities and indications for meniscal repair have broadened. This paper presents the use of an accessory medial portal to facilitate the repair of radial tears of the mid-body of the lateral meniscus. Previous techniques described include all-inside, outside-in, and inside-out repairs, but these techniques can be challenging to achieve optimal simultaneous meniscus reduction, visualization, and suture trajectory. In this Technical Note, we describe the use of an inside-out technique, with emphasis on an accessory anteromedial portal to improve visualization and suture trajectory.

Meniscal Repairs in the Adolescent Knee: Can the Number of Fixation Sites Improve Outcomes?

Background:

Meniscal pathology in children and adolescents is now a common occurrence because of their ever-increasing participation in youth sports.

Purpose:

To investigate the outcomes of arthroscopic meniscal repair in an adolescent cohort and analyze the variables that may affect outcomes, specifically the number of fixation sites utilized during repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective review of all children and adolescents younger than 18 years who underwent arthroscopic meniscal repair at a single institution was performed. Patient characteristics, operative details (eg, tear pattern, tear location, method of repair, and number of fixation sites [determined based on the number of sutures used for repair]), and concomitant procedures were recorded.

Results:

A total of 175 primary meniscal repairs met inclusion criteria and were analyzed. Of this cohort, 115 were able to be contacted and were included in the final study cohort. The mean follow-up was 41 months. The mean age of the children was 14.9 years, and 91 (79%) had concomitant anterior cruciate ligament reconstructions with their meniscal repair. The mean Pediatric International Knee Documentation Committee functional outcome score was 91 (range, 43-100), and the mean Lysholm functional outcome score was 91 (range, 47-100). Of the 115 meniscal repairs, there were a total of 19 reoperations (17%); 15 (13%) were because of meniscal repair failures. The only variable that statistically increased the risk of meniscal repair failure was low number of fixation sites, with the failure group having a mean of 1.79 sutures and the nonfailure group having a mean of 2.97 sutures (P = .03).

Conclusion:

Successful meniscal repairs and a lower failure rate may be achieved with a greater number of fixation sites with promising results at a minimum 2-year follow-up. Validated functional outcome scores were good, with a 13% failure rate. Larger cohort, longer term, multicenter multisurgeon data are still needed to further elucidate the number of fixation sites needed when performing a meniscal repair in the pediatric and adolescent knee.

Variability of Elbow Radiography in the Injured Child: A Potential Diagnostic Dilemma

BACKGROUND

Radiographic imaging is essential in assessing the severity and treatment of injuries. However, when a radiographic series is of poor quality, its diagnostic utility is limited, especially in cases involving pediatric elbow injuries.

OBJECTIVES

This study aims to investigate the variability of elbow radiographs in the injured child, review parameters used to assess diagnostic quality, and introduce the lateral distal humeral metaphyseal-diaphyseal (LDHMD) ratio as a potential measurement of the quality of a lateral elbow radiograph.

METHODS

A retrospective review was performed of elbow radiographs of children who presented to our hospital. Demographic data, injury, location where the radiograph was obtained, and presence of immobilization were collected. Radiographs were subjectively classified as optimal, adequate, or suboptimal based on several radiographic parameters, one of which was the LDHMD ratio.

RESULTS

There were 286 radiographic series reviewed. Per our assessment of the anteroposterior images, 81% were found to be optimal, 18% adequate, and 1% suboptimal. In contrast, only 24% of the lateral images were deemed optimal, 63% adequate, and 13% suboptimal, therefore making the lateral radiographs the focus of our investigation. The LDHMD ratios of the optimal (n = 21) and suboptimal (n = 11) lateral radiographs without definite fracture were 0.96 and 0.84, respectively (p < 0.001).

CONCLUSIONS

An LDHMD ratio that is approximately 1 and an hourglass sign appearing in the anterior third of the humerus are criteria for determining true pediatric lateral radiograph, and with increased awareness, will lead to improved diagnostic utility of radiographs when assessing the injured child's elbow and determining management.

Utility of Bioabsorbable Fixation of Osteochondral Lesions in the Adolescent Knee: Outcomes Analysis With Minimum 2-Year Follow-up

Background:

Osteochondral lesions (OCLs) of the knee, whether occurring secondary to osteochondritis dissecans or a traumatic osteochondral fracture, are commonly encountered in the pediatric and adolescent population. Given the potential for healing in this population, coupled with adequate surgical reduction and stability of OCL fixation, an opportunity exists to avoid a major restorative procedure and the associated substantial costs and potential morbidity.

Purpose:

To analyze the outcomes of bioabsorbable fixation of OCLs in the adolescent knee at a minimum of 2 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

An institutional review board–approved retrospective review was performed of patients younger than 18 years who underwent bioabsorbable fixation of an OCL of the knee with a minimum 2-year follow-up. Patient demographics, operative details, and postoperative clinical findings were detailed and recorded. All cases were performed by a single surgeon.

Results:

There were 38 patients treated surgically for an OCL between 2009 and 2016. Of these, 38 patients (mean age, 14.7 years) were evaluated at a mean of 59 months. OCL fixation consisted of a mean of 1.4 bioabsorbable screws and 1.5 darts. At final follow-up, mean pre- and postoperative Tegner scores were 6.6 and 6.4, respectively, while Lysholm and Pediatric International Knee Documentation Committee scores were 89.8 and 88.1, respectively. A total of 6 patients underwent secondary procedures postoperatively. One patient required a secondary procedure related to OCL fixation, which was secondary to a proud implant. The other secondary procedures included second-look arthroscopic surgery for pain after an injury postoperatively, planned anterior cruciate ligament reconstruction, staged medial patellofemoral ligament reconstruction, and manipulation under anesthesia for arthrofibrosis (n = 2). None of the 32 patients required a revision cartilage procedure at the time of final follow-up.

Conclusion:

The use of bioabsorbable implants in the adolescent knee appears to be a safe and efficacious treatment with good functional outcomes at long-term follow-up and a low revision rate. Additional long-term multisurgeon and multicenter trials with a larger cohort are needed to further elucidate the role of bioabsorbable fixation of an OCL in the adolescent knee.

Relaxation of the Medial Collateral Ligament to Facilitate Pediatric Meniscal Surgery

Meniscal injuries are becoming increasingly common in the pediatric population. During arthroscopic evaluation, pediatric patients typically have pristine articular cartilage and tight medial joint spaces. Therefore, when an arthroscope enters the medial compartment, iatrogenic damage to the articular cartilage may occur. Additionally, proper visualization of the medial meniscus (posterior horn or meniscocapsular junction) can prove to be difficult, and potential pathology may be missed. Proposed methods of increasing medial compartment visualization include the use of a 70° arthroscope placed through the intercondylar notch (Gillquist maneuver), creation of a posteromedial portal, or relaxation of the deep medial collateral ligament (MCL). Similar techniques have been described for use in adults for partial meniscectomy, but not in the pediatric population. The purpose of this Technical Note is to describe the steps to successfully perform the relaxation technique for meniscal repairs in pediatric patients, using an extra-articular outside-in percutaneous method.

Suture Tape Augmentation Repair of the Medial Patellofemoral Ligament

Adolescents with osteochondral loose bodies after a first-time patellar dislocation are most commonly treated with surgical intervention. However, the ideal method of managing a concurrent medial patellofemoral ligament (MPFL) disruption is still unknown. Recent evidence suggests high failure rates are associated with primary MPFL repair. The purpose of this Technical Note is to describe an alternative surgical technique for managing acute first-time patellar dislocations by using high-strength suture augmentation of the MPFL.

The S Sign: A New Radiographic Tool to Aid in the Diagnosis of Slipped Capital Femoral Epiphysis

BACKGROUND

Children with slipped capital femoral epiphysis (SCFE) are often seen by an array of medical professionals prior to diagnosis. Patients with mild slips, slips with knee pain, or bilateral slips can occasionally present a diagnostic challenge that increases the risk of a delay in diagnosis and associated complications.

OBJECTIVES

This study introduces a new radiographic parameter, which we refer to as the S-sign, and analyzes its diagnostic utility on a frog-leg lateral radiograph.

METHODS

Twenty observers reviewed the radiographs from 35 patients with SCFE using Klein's line on anteroposterior pelvis radiographs and the S-sign on frog-leg lateral radiographs to diagnose an SCFE. Analysis included diagnostic outcomes and intraobserver and interobserver reliability.

RESULTS

The S-sign was more accurate at identifying an SCFE compared with Klein's line (92.4% vs. 79.2%, respectively). Sensitivity and specificity was greater for the S-sign compared with Klein's line (89.0% and 95.2% vs. 68.3% and 89.0%, respectively). A combination of the S-sign and Klein's line yielded a sensitivity of 96.5% and a specificity of 85.0%. The combination of tests was more diagnostic for an SCFE, compared with using the Klein's line, which was statistically significant (p < 0.001).

CONCLUSIONS

With increased awareness of the S-sign and a usage of the combined test, clinicians can more reliably and accurately diagnose an SCFE. Clinicians are more likely to diagnose an SCFE using the combined test, compared with solely relying on Klein's line, which we found to be statistically significant.

Definitive Diagnosis of Children Presenting to A Pediatric Emergency Department With Fever and Extremity Pain

BACKGROUND

Children who present to the emergency department (ED) with complaint of fever and new-onset joint or extremity pain can be a diagnostic dilemma for many emergency and consulting physicians.

OBJECTIVES

The purpose of our study was to identify the etiologies of pediatric fever and extremity pain presenting to a tertiary care pediatric ED and to define factors that were associated with advanced imaging, admission, and surgical intervention.

METHODS

The electronic medical records of children presenting to our institution's pediatric ED with fever and extremity pain were retrospectively reviewed. Data collected included demographic characteristics, laboratory studies, diagnostic imaging, need for admission, and surgical procedures.

RESULTS

The initial ED diagnosis was consistent with the definitive diagnosis 42% of the time. Children with the inability to bear weight on the affected limb were more likely to have a bacterial infection, such as osteomyelitis, septic arthritis, or intramuscular abscess (p = 0.016). An erythrocyte sedimentation rate >36 mm/hour and C-reactive protein levels >60 mg/L were found in children with osteomyelitis or septic arthritis (p = 0.043 and <0.001, respectively). Magnetic resonance imaging was ordered in 63% of children with multiple visits compared to 34% of children with a single visit (p = 0.05).

CONCLUSIONS

In addition to a thorough history and physical examination, a complete set of laboratory studies and diagnostic imaging is necessary to reach an accurate diagnosis. The inability to bear weight, elevated C-reactive protein levels, and an elevated erythrocyte sedimentation rate are associated with bacterial infection. Magnetic resonance imaging is a useful imaging modality in determining an accurate diagnosis.

Proximal femur prosthetic interposition arthroplasty for painful dislocated hips in children with cerebral palsy

PURPOSE

Children with cerebral palsy often have musculoskeletal disorders involving the hip. There are several procedures that are commonly used to treat these disorders. Proximal femur prosthetic interposition arthroplasty (PFIA) is an option for non-ambulatory children with cerebral palsy who have a painful, spastic dislocated hip. The purpose of our study was to evaluate the results of PFIA by examining treatment outcomes, complications, and overall effects on the child and their caregiver.

METHODS

Charts were reviewed over a 5-year period at our institution. The focus of the data collection was pain, range of motion (ROM), and overall clinical outcome. Clinical outcome was graded as excellent, good, fair, and poor. Length of follow-up, presence of heterotopic ossification, femoral prosthesis migration, and information provided by competed caregiver questionnaires were analyzed.

RESULTS

A total of 16 hips in 12 patients met the inclusion criteria. Average age at time of surgery was 12 years 1.2 months. Average follow-up was 40.4 months. Three hips required revision surgery. Average time before revision surgery was 16 months. Overall outcomes were excellent/good for seven hips and fair/poor for nine. Pain outcomes were excellent/good for nine hips and fair/good for seven. ROM outcomes were excellent/good for nine hips and fair/poor for seven. The majority of caregivers surveyed would recommend this procedure.

CONCLUSION

Clinical evaluation of the effectiveness of PFIA yielded variable results with this cohort of children with regards to pain and range of motion. Despite these varied results, the majority of caregivers were satisfied with the outcome and would recommend PFIA. PFIA is a salvage option for the painful, spastic dislocated hip, but significant evidence to prove its effectiveness over other salvage procedures is lacking. Based on our results, we conclude that PFIA has the ability to benefit children with cerebral palsy with an acceptable risk profile similar to that reported in recent publications. Level of evidence IV; retrospective case-series.

Reducing Cumulative Arm Overuse Injuries in Young Throwers

As year-round participation in youth sports continues to increase, health care practitioners treating child and adolescent athletes will commonly see injuries that are secondary to overuse. Starting with a clinical vignette, this article describes proximal humeral physeal injuries in youth throwers, examines causative factors, reviews common therapeutic modalities, and focuses on preventive measures aimed at reducing such cumulative arm overuse injuries.

The utility of radiographs prior to pin removal after operative treatment of supracondylar humerus fractures in children

PURPOSE

To determine the safety, utility, and efficacy of pin removal prior to radiographs during the postoperative care of surgically treated displaced pediatric supracondylar humerus fractures.

METHODS

Retrospective review of 532 children with supracondylar humerus fractures treated with closed reduction and pinning from 2007 to 2012. Group 1: children who had their splint/cast removed and radiographs prior to pin removal. Group 2: children with radiographs taken after removal. Data recorded and analyzed included: demographic and radiographic data at the time of surgery and at final follow-up, including the number of radiographs taken prior to pin removal and if pins were ever retained after radiographs were performed on the date of intended removal.

RESULTS

There was no difference between the groups' demographics. The number of postoperative radiographs taken prior to pin removal ranged from zero to two. No statistically significant change in Baumann's (p = 0.79) or lateral humeral capitellar angles (p = 0.19) was noted between the groups. No children in group 1 (0/438) had their pins retained after radiographs were taken on the date of intended removal.

CONCLUSION

Obtaining postoperative radiographs prior to pin removal, although commonplace, is not necessary. If fracture stability is noted intraoperatively, and there is an uneventful postoperative course, it is safe and effective to discontinue immobilization and remove pins prior to X-ray. This is safely done without change in alignment or clinical sequelae. Doing so can aid in clinic flow, may decrease child anxiety, and limit multiple cast room visits.

LEVEL OF EVIDENCE

Level III therapeutic study.

The passive distraction test: a new diagnostic aid for clinically significant superior labral pathology

PURPOSE

The purpose of this report is to present a new provocative maneuver, the passive distraction test (PDT), as an examination tool to be used in the evaluation of patients thought to have a SLAP lesion and to compare its accuracy, precision, and reproducibility alone and in conjunction with previously published maneuvers.

METHODS

A retrospective analysis of 319 consecutive arthroscopies performed between May 2001 and November 2003 was performed. A total of 65 cases were excluded, 53 because of limitation of elevation to less than 150 degrees or pain in the starting test position and 12 who had previous shoulder procedures performed by the senior author, leaving 254 cases for review. A thorough history was obtained and a thorough physical examination performed with a focus on the involved shoulder including specific provocative maneuvers for the clinical diagnosis of a SLAP lesion. The active compression test, the anterior slide test, and the PDT were used to clinically diagnose a SLAP lesion. The results from the 3 provocative maneuvers were compared with the arthroscopic findings to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of each test alone and in a logical combination.

RESULTS

Of 254 shoulder arthroscopies, 61 had a clinically significant SLAP lesion, for an incidence of 24%. The sensitivity and specificity for the PDT were 53% and 94%, respectively, with an NPV of 87% and positive predictive value of 72%. In combination, the PDT and the active compression test yielded an NPV of 90.5%.

CONCLUSIONS

The PDT can be used alone or in combination to aid in the clinical evaluation and diagnosis of a SLAP lesion.

LEVEL OF EVIDENCE

Level IV, retrospective, diagnostic, sensitivity-specificity study.